Provider Demographics
NPI:1912205725
Name:CONSULTING PSYCHOLOGY OF WESTERN ARKANSAS, INC.
Entity Type:Organization
Organization Name:CONSULTING PSYCHOLOGY OF WESTERN ARKANSAS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PATTY
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-785-1995
Mailing Address - Street 1:1401 S WALDRON RD STE 206
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-2590
Mailing Address - Country:US
Mailing Address - Phone:479-785-1995
Mailing Address - Fax:479-785-4248
Practice Address - Street 1:1100 S WALDRON RD
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-2552
Practice Address - Country:US
Practice Address - Phone:479-785-1995
Practice Address - Fax:479-785-4248
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-02
Last Update Date:2018-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR90-18P103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR118624719Medicaid
AR118624719Medicaid